Response

This paper has presented several salient points for discussion and we commend the authors on conducting a valuable and relevant study. ^{Reference Battle, Álvarez-Mon, Lara-Abelenda, Perez-Araluce and Pinto da Costa1} As resident doctors in psychiatry and individuals who are active on social media platforms, the conclusions from the study are in line with our own experiences of perceptions of the profession in both the clinical setting and online. We have observed that the stigma against psychiatry persists and often shows a demographic pattern. Older patients may hold more traditional misconceptions of mental health and fear diagnostic labels, whereas younger patients are increasingly seeking confirmation of diagnoses they already suspect they have and can be more forthcoming with symptoms. ^{Reference Baral, Prasad and Raghuvamshi2} As younger patients are more likely to be using social media, this could reflect the apparent reduction in stigma against mental health.

We note the study omitted ‘mental illness’ as a search term and showed positive perceptions towards ‘mental health’. Presumably, the former term would have been associated with more negative connotations and this could explain the ostensible difference in perceptions between psychology and psychiatry. As the authors note, engagement with psychology is often viewed as voluntary and psychiatry is more often associated with involuntary treatment and the use of statutory powers. In Scotland, there is a rising trend of involuntary treatment, with a total of 7109 detentions between 2023 and 2024: 1.7% of these were compulsory treatment orders, and 45.6% of these were community-based. ³ We acknowledge the incidence and trends may vary internationally.

An aspect that has not been touched upon is the difference in emphasis placed upon the therapeutic relationship in both professions. This relationship, while important in psychiatric practice, is more integral to psychological treatment. ^{Reference Opland and Torrico4} When the relationship deteriorates in psychology, therapy often cannot continue, as opposed to psychiatry where other alternatives remain available. In our experience working in the National Health Service, the patient population for psychology can be somewhat self-selective, potentially influencing the way in which they describe their experiences. Encouragingly, it has been observed that the introduction of ‘open-door’ policies in in-patient psychiatric care can lead to better patient satisfaction, indicating a possible path to improved psychiatric therapeutic relationships. ^{Reference Campillo-Carrión, Rius, García, Olivero, Sánchez-Tomico and Martínez-García5}

The nature of engagement on Twitter/X must also be considered when examining discourse. It is known that the number of users, as well as posts, has been increasing over time, particularly during the COVID-19 pandemic. ^{Reference Alshamrani, Abusnaina, Abuhamad, Lee, Nyang, Mohaisen, Chellappan, Raymond Choo and Phan6} A large, sustained increase in posts in 2021 relating to ‘mental health’ was noted by the authors. This could perhaps point towards increased use of services, in line with greater prevalence of mental illness. ^{Reference Wu, Jia, Shi, Niu, Yin and Xie7} It is possible awareness of and subsequent attitudes towards psychiatry improved after utilising services.

We have noted possible limitations to this study. Tweet Binder, while a useful tool to analyse discourse, only has access to public tweets. We posit that as a result of stigma towards mental health, a significant proportion of people may be unwilling to share their personal experience publicly, whether positive or negative. For example, a patient may not wish to inform the public of their involuntary detention, even if the ultimate outcome was positive. Of note, the majority of Twitter/X accounts are thought to be public (though there are no publicly available data with definite figures), and so the limitations of only analysing public discourse may not be as significant. Often, anonymous accounts can be created for the purpose of discussing difficult issues.

While the authors have commented on the stigma enacted by the public, this would inevitably include medical professionals. In our experience, there is a negative attitude towards psychiatric services from some corners within the profession. ^{Reference Ng, Tan, Goo and Al-Najjar8} It is important to be aware of this negative attitude to help facilitate access to services for the public, ourselves and our colleagues.